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24 October 2014

The old lady was taking lots of pills – and then she got confused

Each one of Elsie’s tablets, viewed in isolation, had seemed a good idea. But clinical trials are usually performed on patients with single conditions, so they tell us nothing about the perils of heaping drug upon drug on people.

By Phil Whitaker

In past centuries, barbaric practices were pursued by doctors in the name of healing. Bloodletting rendered sick people anaemic and more likely to succumb to their original illness. Purging inflicted diarrhoea and dehydration on those already fighting for their life. We now tut and shake our head, and thank our lucky stars that we live in a modern, rational age where such things could never happen. Except that, in every hospital and GP surgery in the country, a comparable barbarity is being perpetrated.

The practice goes by the innocent-sounding name of polypharmacy, meaning “many drugs”. Most people agree that polypharmacy exists when a patient is taking more than four medications on a regular basis. There are plenty of patients prescribed two, three or even four times that number, swallowing in excess of 20 pills every day.

Consider Elsie, a grandmother in her early eighties, who was being treated with powerful painkillers for arthritis, something to calm her irritable bladder, and antidepressants for her low mood. Additionally, she was being given tablets to ward off possible sequelae from raised blood pressure, furring of the arteries, an irregular pulse rate, and maturity-onset diabetes.

Elsie started to become confused, to a point where she was a danger to herself – leaving appliances on, wandering from home. Initial tests showed declining kidney function, unsurprising at her age, but nothing else. She was given emergency admission to a nursing home some miles away, dislocating her from her familiar environment, which made her confusion worse. She came under the care of a new set of doctors with no prior knowledge of her, who initially saw her as another complex older patient with dementia.

It took time, and painstaking detective work, for the true picture to emerge. Some of Elsie’s blood-pressure treatments and painkillers were affecting her kidneys, leading to an accumulation of other drugs in her system. Two in particular – her antidepressant, and one of her powerful painkillers – had begun to interact, causing progressive disturbance in brain function. When the offending drugs were finally withdrawn, Elsie regained her previous mental clarity. However, the months of infirmity had led to her muscles becoming irretrievably weakened, and she was never able to manage back at home, condemned to live out her days in residential care.

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Each one of Elsie’s tablets, viewed in isolation, had seemed a good idea: there’s mountains of evidence from clinical trials (funded by the drug manufacturers) to justify their prescription. But clinical trials are usually performed on patients with single conditions, and so they tell us nothing about the perils of heaping drug upon drug in people with multiple problems.

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More insidious is the deprofessionalisation affecting medicine (as well as other areas of life such as education) over the past 15 years. Many individual doctors know that polypharmacy is asking for trouble, yet we are subject to the government’s Quality and Outcomes Framework, which dictates, through its rigid performance targets, both the scope and aggressiveness with which we are supposed to “treat” patients such as Elsie.

The physicians of yesteryear who bled and purged patients did so with the best of intentions. No one adding yet another tablet to the panoply of pills taken by Elsie did so intending any harm. But recent research has shown that one can safely stop approximately two-thirds of the drugs given to polypharmacy patients. As a result, the patients report significant improvements to their health and well-being, and very few tablets ever need to be restarted.

No one knows how many nauseous, giddy, confused, falling, constipated, drowsy folk there are out in the community, slowly being poisoned by their doctors. There will come a time when physicians of the future, looking back on our polypharmacy and the government diktats that compel the abdication of professional judgement, will tut and shake their heads.

Until we regain our professionalism, it will be the likes of Elsie who pay the price for our folly.